STIs and Genital Infections Flashcards
List common bacterial STIs
Chlamydia
Gonorrhoea
Mycoplasma genitalium
Syphilis
List common viral STIs
Genital warts - HPV
Genital herpes
Hepatitis and HIV
List common parasitic STIs
Trichomonas vaginalis
Pubic lice - Phthirus pubis
Scabies
Why does gonorrhoea produce purulent discharge
Generally they produce an intense neutrophil response in the male urethra
Coinfections of STIs are common - true or false
STI pathogens move together
Gonorrhoea and chlamydia cause urethritis
Genital ulcers greatly increase the probability of HIV acquisition.
Is it normal to find bacteria in the vagina
Yes it has a normal flora
Lactobacillus spp. predominate and are protective
Strep and candida are normal in small numbers
What are some predisposing factors for candida infection
Recent antibiotic therapy
High oestrogen levels (pregnancy, certain types of contraceptives)
Poorly controlled diabetes
Immunocompromised patients - CD4 counts below 100 are predisposed to this
condition
How does a candida infection present
Intense itch
White vaginal discharge - like cottage cheese
How do you diagnose a candida infection
Often just clinical
Can do a high vaginal swab for culture
How do you treat a candida infection
Topical clotrimazole cream - treats external symptoms
Clotrimazole pessary
Oral fluconazole
Non-albicans Candida species
More likely to be azole resistant
How does candida balanitis present
Spotty rash on the penis
Not sexually transmitted
How does gonorrhoea affect cells
Attaches to host epithelial cells and is endocytosed into the cell
It replicates within the host cell and is released into the sub epithelial space
Where does gonorrhoea usually infect
Urethra
Rectum
Throat and eyes
Endocervix in females
Describe Neisseria gonorrhoea
Gram negative diplococcus
Often appear intracellularly as easily phagocytised
Looks like 2 kidney beans facing each other
Doesn’t survive well outside the body
How do you test for gonorrhoea
Gram stain and microscopy of urethral/endocervical swabs - done at sexual health clinic to confirm/exclude presence
NAAT testing carried out on swab (female) or first void urine sample (male)
What is a Nucleic acid amplification test
Test for chlamydia and gonorrhoea
Test first pass urine specimens from men and self-obtained vaginal swabs
More sensitive than culture
What is the most common bacterial STI in the UK
Chlamydia
Where does chlamydia usually infect
Urethra
Rectum
Throat and eyes
Endocervix
How do you treat chlamydia
Doxycycline 100mg bd x 7 days
Less commonly Azithromycin (1g oral dose)
If pregnant or at risk of pregnancy then azithromycin, erythromycin or amoxicillin may
be used.
Can chlamydia be gram stained
No
There is no peptoglycan in the cell wall so it wont stain
Can chlamydia reproduce outside a host cell
No
What are the 3 serological groups of chlamydia
Serovars A-C = Trachoma (eye infection) (NOT an STI)
Serovars D-K = Genital infection
Serovars L1-L3 = Lymphogranuloma venereum (tropical and MSM)
What type of urine sample must be used for a NAAT STI test
First pass only
Used to test male patients
How does trichomonas vaginalis present
Vaginal discharge (yellowish, frothy)
Vulvovaginitis: itch/discomfort
Strawberry cervix (microhaemorrhages)
Vaginal pH > 4.5
Men are usually asymptomatic but may get urethritis
What is trichomonas vaginalis
Single celled protozoal parasite
Human host only
transmitted by sexual contact
How do you diagnose trichomonas vaginalis
High vaginal swab for microscopy
PCR test available but not used in tayside
How do you treat trichomonas vaginalis
Oral metronidazole for 5-7 days
Describe the discharge seen in bacterial vaginosis
Homogenous and may contain bubbles
Grey/white in colour
Fishy odour - offensive
How do you test BV discharge
Adding 10% potassium hydroxide to the discharge on the slide elicits an amine-like, fishy odour, yielding a positive “whiff” test
A wet mount of the sample from the vagina will show
clue cells.
The absence of bacilli and their replacement
with clumps of coccobacilli also leads to the diagnosis
What are the potential complications of BV
increased rate of upper tract infection (endometritis, salpingitis)
Premature rupture of the membranes and preterm delivery
Increased risk for the acquisition of HIV
How do you treat BV
Metronidazole oral for 7 days
Relapse rate is 30%
How can you diagnose syphilis
Can do PCR test of swab from lesions
Dark Field Microscopy - not done in tayside
Doesn’t gram stain and cant be grown in culture
Or serological blood tests can be done as a screening test
How many stages does syphilis have
Primary lesion/infection - up to 3 months
Secondary stage - up to 2 years
Latent stage
Late stage
Describe primary syphilis
Presents with painless lesion (chancre) at inoculation site
Will have non-tender local lymphadenopathy
Organism multiplies at site and gets into bloodstream
Chancre heals
Describe secondary syphilis
Large number of bacteria circulating in the blood
Multiple manifestations at different sites
Snail-track” mouth ulcers, generalised rash,
generalised lymphadenopathy, flu-like symptoms, pharyngitis,
patchy alopecia etc.
Neurological and ophthalmic
involvement not uncommon
Describe latent stage syphilis
No symptoms, but low-level multiplication of spirochaete in intima of small blood vessels
Some patients will self-cure or
be treated inadvertently
Describe late stage syphilis
Cardiovascular or neurovascular complications many years later
How do you diagnose syphilis
Primary : dark ground microscopy, PCR, IgM
Secondary: serology ( specific and nonspecific)
Tertiary : serology (non-specific antibodies first then specific test TPPA done if positive)
How do you treat syphilis
It is very sensitive to penicillin
Injectable long-acting preparations of penicillin used for treatment - IM
1 injection in early disease and 3 if late
What causes genital herpes
Herpes simplex virus type 1 (which also causes “cold sores”) and type 2
More commonly type 2
How is genital herpes spread
Transmitted by close contact with someone shedding the virus
Spread by either genital/genital or oropharyngeal/genital contact
How does genital herpes affect the body
Virus replicates in dermis and epidermis
Gets into nerve endings of sensory and autonomic nerves
Nerve endings get inflamed and you get small vesicles - easily deroofed
Virus migrates to the root ganglion and hides from immune system - becomes latent
Can reactivate from here causing recurrent genital herpes
How do you diagnose genital herpes
Swab in virus transport medium of deroofed blister for PCR test – highly sensitive and specific test
No good test for inactive infection
How do you treat genital herpes
Aciclovir may be helpful if taken early enough
Pain relief - topical lidocaine or analgesia
Saline bathing
Avoid sexual contact until episode is over
How are pubic lice spread
Acquired by close genital skin contact
How do pubic lice present
Lice bite skin and feed on blood, which causes itching in pubic area
How do you treat pubic lice
malathion lotion
How do you treat gonorrhoea
IM ceftriaxone (1g) first line
Cefixime 400 mg oral and azithromycin 2g oral
Test of cure needed for all patients
How long do you have to wait for a test of cure for gonorrhoea
5 weeks
Do you need to treat sexual partners of patients who present with thrush
Only if they show symptoms
How does genital herpes present
Small blisters on the genitals - vesicles which then become pustular Extremely painful Vulval inflammation Difficulty passing urine Local lymphadenopathy Fever and myalgia
How do you treat genital warts
Cryotherapy
Topical:
Podophyllotoxin cream
Imiquimod (Aldara)- immune modifier
Electrocautery
Curettage
Excision
Can chlamydia be asymptomatic
YES
70-80% of women, 50% of men are asymptomatic
How is chlamydia spread
Vaginal, oral or anal sex
Or genital contact with an infected partner
Pregnant women can pass on the infection to infants during birth
What are the complications of untreated chlamydia
PID
This increases the risk of chronic pain, ectopic pregnancy and tubal factor infertility
Adhesions can form
Epididymo-orchitis and proctitis in men
Reactive arthritis, conjunctivitis and urethritis are a common triad - Reiter’s syndrome
Babies can also get pneumonitis and eye infection due to chlamydia
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
How does chlamydia present in women
Post coital or intermenstrual bleeding secondary dysmenorrhoea Lower abdominal/pelvic pain Deep dyspareunia Mucopurulent cervicitis - discharge Dysuria Rectal pain and/or discharge
Can be asymptomatic!
How does chlamydia present in men
Urethral discharge - clear and milky Dysuria Urethritis Epididymo-orchitis Proctitis
Can be asymptomatic!
What is LGV
Lymphogranuloma venereum
Serovars of Chlamydia - more invasive and gives more disease
Who is most likely to get LGV
Men who have sex with men
How does LGV present
Rectal pain, tenesmus discharge and bleeding - proctitis
Can look like Crohn’s
High risk of concurrent STIs (67% HIV)
How do you diagnose chlamydia
Test 14 days following exposure if asymptomatic - due to incubation period
NAAT- females (vulvovaginal swab), males (first void urine or urethral swab)
MSM (add rectal swab if has receptive anal intercourse and pharyngeal)
Describe mycoplasma genitalium infection
Emerging STI
Often asymptomatic
Diagnose with the NAAT test
Tested if people fail treatment for PID and NGU
How long do you have to wait to test for gonorrhoea
Incubation time is 2-5 days
Still advised to wait 14 days as its in the same test as chlamydia (which has longer incubation)
How does gonorrhoea present in men
Can be asymptomatic Urethral discharge -green/yellow mucopurulent Dysuria Testicular pain Pharyngeal/rectal infections
How does gonorrhoea present in women
Asymptomatic (up to 50%) Increased/altered vaginal discharge Dysuria Intermenstrual/post-coital bleeding Cervicitis Pelvic pain Pharyngeal and rectal infection are usually asymptomatic.
What are some of the complications of gonorrhoea
Bartholintiis or tysonsitis - infected genital glands
Bartholin’s abscesses
PID - can lead to ectopics and infertility
Hydrosalpinx
Urethral strictures
Epididymo-orchitis
Proctocolitis resulting in strictures, abscesses and fistulae
Infection can become disseminated and lead to septic arthritis etc.
Which infection is more likely to cause severe complications - chlamydia or gonorrhoea
Chlamydia
What is the difference between a primary herpes episode and non-primary episode
Primary – never been exposed to herpes before
Non-primary – have been exposed to the virus before (have antibodies) but this is the first symptomatic presentation
Which type of herpes virus is most likely to cause recurrent infections
HSV type 2
How and when should you suppress herpes
Suppression needed if they have 6 or more attacks per year
Aciclovir 400mg bd is given for 12 months – should stop recurrence for that year
What is the risk of herpes in pregnancy
Risk of giving it to the baby and it can spread to their brain
Less worrying if they’ve had herpes before as they will have antibodies that will be passed on to babies
What are the high risk types of HPV
16, 18,
Also 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68
Which types of HPV are vaccinated against
6, 11, 16, 18
Adding 31, 33, 45, 52, 58
Is HPV common
VERY
80% of populations are exposed at some point
Very few go on to develop warts - around 1%
Do all warts need treated
About 20% will spontaneously clear
Most need treatment
20% will not respond to treatment
How is syphilis transmitted
Sexual contact
Trans-placental/during birth
Blood transfusions
Non-sexual contact – healthcare workers
When is syphilis screened for outside the SRH clinic
Pregnant women - screened at 8-12 weeks
Blood donations
What is chemsex
Drugs are used to prolong and enhance sex
Higher risk of having multiple partners and trauma which increases infection risk
Why is early detection of HIV important
Allows us to prevent AIDS
Treatment can lead to normal life expectancy
How does AIDS kill
Opportunistic Infections - pneumonias, fungal infections
AIDS-related cancers - Kaposi
Where did HIV originate
In primates in West-Africa
Spread to humans in the 1930’s/40’s
Which cells does HIV target
HIV infects cells with CD4+ surface glycoprotein
It targets the receptors
This includes T helper lymphocytes, dendritic cells, macrophages and microglial cells
Lymphocytes are the main ones affected
What type of virus is HIV
Retrovirus - type of RNA virus
Meaning when it makes DNA it uses reverse transcriptase to turn single stranded RNA to DNA
What effect does HIV have on the immune response
Reduces circulating CD4 cells by sequestration of cells in lymphoid tissues
Reduced proliferation of CD4+ cells
Reduction CD8+ (cytotoxic) T cell activation– makes you more susceptible to opportunistic infection
Reduction in antibody class switching - less effective antibodies produced
In a constant state of immune activation
What does HIV make you more susceptible to
Viral infections
Fungal infections
Mycobacterial infections
Infection-induced cancers
At what CD4+ count do become at risk of opportunistic infection
200 cells/mm3
Normal is 500-1600 cells/mm3
How quickly does HIV replicate
Very rapidly in early and very late infection
New generation every 6-12 hours
Reverse transcriptase works very fast to produce new virus – doesn’t go through the same rigorous checking as normal DNA
How does HIV infect the body
Enters the body across a mucosa - usually via sexual intercose
Infection of mucosal CD4 cell - often dendritic cells which are found here
Infected cells are transported to regional lymph nodes
Here the virus spreads rapidly and infects other cells at the lymph nodes such as T helper cells
and macrophages
Infection established within 3 days of entry
Dissemination of virus
What is the window period for giving post-exposure prophylaxis for HIV
72 hours
After this time the infection is too well established to prevent
How does primary HIV infection present
Up to 80% present with symptoms around 2-4 weeks after infection
Combination of fever, rash (maculopapular), myalgia, pharyngitis, headache/aseptic meningitis
Flu like or glandular fever like illness – more than a cold
Is transmission high in the primary infection of HIV
Yes very high at this stage of illness
This is because there is a big spike in the amount of virus in the blood at this point
What is the definition of an opportunistic infection
An infection caused by a pathogen that does not normally produce disease in a healthy individual. It uses the “opportunity” afforded by a weakened immune system to cause disease
List some opportunistic infections that may be a sign of HIV
Toxoplasmosis Pneumocystis pneumonia TB CMV Herpes zoster or simplex HPV
Describe toxoplasmosis infection
Caused by Toxoplasma gondii.
Lots of people exposed as cats have it but doesn’t usually make us ill
Leads to multiple cerebral abscess
Presents with headache, fever, focal neurology, seizures, reduced consciousness and raised ICP
How does pneumocystis pneumonia present
Insidious onset
SOB and dry cough
Exercise desaturation = Exercise for 5 mins and sats will often plummet
CXR can be normal – often looks more like heart failure than consolidation
How do you diagnose pneumocystis pneumonia
Bronchial-alveolar lavage and immunofluorescence
+/- PCR
How do you treat pneumocystis pneumonia
High dose co-trimoxazole (+/- steroid)
Lower dose can be used for prophylaxis for all patients with CD4 <200
Describe CMV infection
Also a very common virus
Can reactivate if you become immunosuppressed
Causes retinitis, colitis, oesophagitis
Presents with reduced visual acuity, floaters, abdo pain, diarrhoea, PR bleeding
Why do women with HIV need annual cervical screens
They are at a much higher risk of HPV causing dysplasia
Can HIV cause neurological problems
Yes
HIV itself is a neurotoxic agent
Leads to reduced short term memory and motor dysfunction
Also makes you more susceptible to neurological infections
What is progressive multifocal leukoencephalopathy
Neurological condition caused by JC virus Seen in immunosuppression - CD4 <100 Rapidly progressing Focal neurology Confusion Personality change
What is slim’s disease
HIV associated cachexia
May be caused by metabolic dysfunction, anorexia, malabsorption and hypogonadism
What is Kaposi’s sarcoma
An AIDs related vascular tumour
Caused by human herpes virus 8
Can occur at any CD4 but more common as you decline
Tumours can be cutaneous, mucosal or visceral – pulmonary, GI
How do you treat Kaposi’s sarcoma
HAART
Local therapies
Systemic chemotherapy
Name the AIDS-related cancers
Kaposi’s sarcoma
Non-Hodgkin’s lymphoma
Cervical cancer
What causes non-Hodgkin’s lymphoma in AIDS
EBV - higher incidence with immunosuppression
List some general symptoms of HIV infections
Mucosal candidiasis Seborrhoeic dermatitis Diarrhoea Fatigue Worsening psoriasis Lymphadenopathy Parotitis Epidemiologically linked conditions (STIs, Hep B and C)
List some of the haematological manifestation of HIV
Anaemia
Thrombocytopenia
Neutropaenia
Lymphopaenia
What factors increase risk of sexual transmission of HIV
Anoreceptive sex
Trauma
Genital ulceration
Concurrent STI
How is HIV transmitted
Sex - 95% of new infections Injection drug use - sharing needles Infected blood products - rare now Iatrogenic Mother to child
How can a mother pass HIV onto her child
In utero/trans-placental
Delivery
Breast-feeding
Without treatment the ¼ will be infected and 1/3 will die before age of 1
Where is HIV most prevalent
Africa - particularly sub-Saharan
Which societal groups are most affected by HIV
Men who have sex with men
Female partners
of bisexual men
Black African men and women
People who inject drugs - shaare needles
Partners of people
living with HIV
Adults, children and those with sexual partners
from endemic areas
Children born to HIV+ or untested mothers from endemic areas
Who should be tested for HIV
Universal testing in high prevalence areas
Screening of high risk groups
Testing in the presence of “clinical indicators”
Opt-out testing at GUM clinics,, TOP services, antenatal services, assisted conception services
How do you take an HIV test if the patient is incapacitated
Only test if in patient’s best interest
Consent from relative not required
If safe, wait until patient regains capacity
Obtain support from HIV team if required
Which markers of HIV can be used to detect infection
Viral RNA
Antigens - fastest
Antibodies - take up to 3 months to appear
What is the window period for a 4th generation HIV test
14-45 days
Combined antibody and antigen test
Carried out on blood sample
How quick are the rapid HIV tests
Fingerprick blood specimen or saliva
Results within 20-30 minutes
Can be 3rd generation tests which are antibody only, whereas 4th are antigen/antibody
What are the advantages of rapid HIV tests
Simple to use No lab required No venepuncture required No anxious wait Reduce follow-up Good sensitivity
What are the disadvantages of rapid HIV tests
Expensive ~£10 Quality control Poor positive predictive value in low prevalence settings Not suitable for high volume Can’t be relied on in early infection
List some targets for anti-retroviral drugs
Enzymes:
Reverse transcriptase
Integrase
Protease
Can also block entry and maturation of the virus
What is involved in highly active anti-retroviral therapy (HAART)
A combination of 3 drugs from at least 2 drug classes to which the virus is susceptible
List examples of HIV drugs
Tenofovir
Emtricitabine
Efavirenz
Nevirapine
What are some of the side effects of highly active anti-retroviral therapy
GI side effects Skin rashes, hypersensitivity Steven Johnsons Mood changes Psychosis Renal toxicity Osteomalacia Increased MI risk Anaemia
Is partner notification compulsory
No its voluntary
Can take a long time to contact people
Can be done by the clinician with patient consent
How can you prevent HIV transmission
Condom use HIV treatment STI screening and treatment Disclosure Post-exposure prophylaxis Pre-exposure prophylaxis
How can you prevent transmission of HIV from mother to child
HAART during pregnancy Vaginal delivery if undetected viral load Caesarean section if detected viral load 4/52 PEP for neonate Exclusive formula feeding
What conception options are there for a HIV+ man and a negative female partner
Treatment as prevention
PrEP for partner
What conception options are there for a HIV+ woman and a negative male partner
Treatment as prevention
Artificial or self insemination
PrEP for partner
What is the eligibility criteria for PrEP
Age over 16 HIV negative Can commit to 3/12’ly follow-up Willing to stop if eligibility criteria no longer apply Resident of Scotland
Given to high risk groups or people with HIV+ partners
How can we prevent HIV
Condom programmes Behavioural change programmes Treatment and support of those living with HIV Increase uptake of testing Prevent children being born with HIV
What are the roles of the sexual health clinic
Diagnosis and management of STIs Partner notification Infection prevention Genital dermatology Contraception Community gynaecology Menopause Psychosexual counselling
Which infections do not need partner notification
Warts
Herpes
Vaginal thrush
BV
What is the partner notification look back period for gonorrhoea
Male urethral - 2 weeks
Any other - 3 months
What is the partner notification look back period for HIV
4 weeks before a previous negative test or before most likely time of infection
What is the partner notification look back period for chlamydia
Male with symptoms- 4 weeks prior to symptom onset
Any other patients - 6 months
What is the partner notification look back period for syphilis
Primary - 90 days
Secondary - 2 years
Other infection - 3 months prior to negative test
Who gets vaccinated against Hep B
MSM High prevalence countries (travellers) Sexual assault Contacts Healthcare workers
Who gets vaccinated against Hep A
MSM
What drugs are used in PrEP
Tenofovir disoproxil / emtricitabine
How is PrEP taken
Medicine taken before exposure to HIV to reduce risk of infection
Can be taken on daily or event-based basis
Given to high risk patients
What infections have post-exposure prophylaxis available
Hep B - vaccine can be given up to 7 days later
HIV - anti-retrovirals given within 72hrs for 28 days
What treatment is needed for a recent rape victim
Consider forensic examination Immediate safety Injuries Emergency contraception HBV vaccination HIV PEP STI/pregnancy care Counselling
What are the risk factors for gender-based violence
Being female Disability Pregnancy Addictions HIV
How long should you abstain from sex after a chlamydia diagnosis
At least 2 weeks
When would you test for chlamydia
If they have symptoms - urethritis, pain etc.
If they have been contact traced
If they have any other STI
Asymptomatic screening in high risk groups
When would you test for gonorrhea
If they have symptoms - urethritis, pain etc.
If they have been contact traced
If they have any other STI
Asymptomatic screening in high risk groups
What is the testing window period for syphilis
Test only accurate 3 months after sexual contact
What is the testing window period for HIV
Confirmed after 45 days
Can get a good indication after 4 weeks with a 4th generation test - commonly used
Which STI tests would be offered to a man who has sex with men in a general screen
- First pass urine sample for chlamydia and gonorrhoea (tested by NAAT testing)
Rectal swab for chlamydia and gonorrhoea (NAAT)
Pharyngeal swab for chlamydia and gonorrhoea (NAAT)
Blood sample for HIV and syphilis
Also test for Hep B - bloods
How is Hep B tested for
Blood test
You would test for core antibody first line which would be positive in both past and current infection.
If it was positive then surface antigens are tested as these would be positive in a current infection only.
Which vaccinations are offered to MSM
HPV
Hep B and Hep A
Chlamydia is most common in which population groups
Mainly in young men and
women aged under 25.
Higher incidence in females than males in Scotland.
Do you need a test of cure for chlamydia
No
Unless the patient is pregnant, there is a risk of reinfection or
the treatment compliance is in question.
A test of cure is routine for rectal infections.
When would you treat men empirically for trichomonas
If they have recurrent/persistent non-chlamydial, non-gonococcal urethritis
Male contacts of affected women are also treated.
Which types of HPV cause genital warts
Type 6 and 11
How do genital warts present
Non-painful, non-pruritic genital lumps
Do you need a test of cure in syphilis
Yes
RPR (rapid plasma reagin) –essential for
monitoring response to therapy, often never
becomes negative
Test for RPR for 12 months to ensure a four-fold reduction
What causes syphilis
Caused by coiled spirochete bacterium Treponema pallidum
How does genital herpes present
Blistering ulcer(s) at external genitalia Pain External dysuria Vaginal or urethral discharge Local lymphadenopathy Fever and myalgia
Which type of herpes virus is more likely to cause recurrent herpes
HSV2
How does recurrent herpes present
Mild anogenital tingling, burning or itching Usually unilateral small vesicles or ulcers which heal with scabbing on keratinised skin. Minimal systemic symptoms Recurrences last up to 7 days
Which species of candida is most likely to cause thrush
C. albicans
How does prostatitis present
Symptoms of UTI,
Lower abdominal pain/back/perineal/penile pain
Obstructive voiding symptoms
Fever and rigors
Digital rectal examination will reveal a tender, boggy prostate gland
What causes prostatitis
Usually caused by E. coli, other coliforms and Enterococcus sp.
May also (very uncommonly) be caused by gonorrhoea or chlamydia Therefore, men under the age of 35 presenting with prostatitis should be screened for STIs.
List risk factors for prostatitis
Recent a urogenital procedure Recent prostate biopsy Intermittent bladder catheterisation Recent urinary tract infection (rare)
How do you diagnose prostatitis
MSSU for culture and sensitivity
(+/- first pass urine for chlamydia/gonorrhoea
tests)
Acute bacterial prostatitis can progress to what
Chronic bacterial prostatitis (<5% of cases) or Chronic prostatitis/chronic pelvic pain
syndrome (CP/CPPS)
How do you treat prostatitis
ofloxacin 400mg bd for 28 days
If a MSM presents with prostatitis what other test should be done
Should also been screened for rectal gonorrhea
Is bacterial vaginosis an STI
NO
However, it is almost exclusively seen among
sexually active women and more frequent where other risks for STIs exist.
It is more
common in women whose sexual partners are women.
How does BV affect the vaginal pH
It is usually found to be >4.5
This due to the
overgrowth of anaerobic organisms leading to a
consequent fall in lactic acid producing aerobic
lactobacilli resulting in a raised vaginal pH
Large numbers of leukocytes in the wet mount of a woman with BV suggest what
A coincident
infection, possibly trichomoniasis or bacterial cervicitis
What is the most common cause of BV
Gardnerella vaginalis, a species of anaerobic bacteria
List risk factors for blood borne viruses
Current or past history of history of injecting
drugs
Sex with a partner from or in a country with
a high HIV or Hep B prevalence
MSM or women who have had sex with HSM
If they have ever exchanged
money in return for sex
Medical treatment / tattooing where sterility
cannot be guaranteed
Which STIs require partner notification
HIV
- Gonorrhoea
- Chlamydia
- Trichomoniasis
- Syphilis
- Lymphogranuloma venereum
- Pelvic inflammatory disease
- Hepatitis A, B and C
- Epididymo-orchitis
- Mycoplasma genitalium
- Non-gonococcal urethritis
Which type of HIV is more likely to progress to AIDS
HIV-1
HIV-2 is rarer
Can someone be immune to HIV
YES
Some
people have mutations in the CCR5 co-receptors which are used by HIV to enter the cell
This means they are immune to infection by a
CCR5-using virus.
If the mutation is homozygous, they are immune, if its heterozygous the disease will slowly progress.
At which stage of infection does the immune system start to act against HIV
It kicks in and lowers levels of the virus in the blood by 12 weeks (still detectable). At this point the patient enters the chronic and clinically asymptomatic phase (lasting between 2-10 years)
Describe the chronic phase of HIV infection
The body’s immune system lowers the viral load after around 12 weeks
The patient becomes clinically asymptomatic
Virus would still be detectable on testing
This phase can last between 2-10 years
During this chronic phase T cells may have a level
of >500 cells/mm3 however this is still enough to fight infection
List some respiratory manifestations of HIV
Respiratory tuberculosis
Pneumocystis Pneumonia
Aspergillosis
Bacterial pneumonia
List some GI manifestations of HIV
Persistent cryptosporidiosis Oral and oseophageal candidiasis Oral hairy leukoplakia Chronic diarrhoea of unknown cause Weight loss of unknown cause Salmonella, shigella or campylobacter Hepatitis B infection Hepatitis C infection
List some neurological manifestations of HIV
Cerebral toxoplasmosis Progressive multifocal leukoencephalopathy HiV-associated neurocognitive impairment - reduced short-term memory with/without motor dysfunction Aseptic meningitis /encephalitis Primary cerebral lymphoma Cerebral abscess Cryptococcal meningitis Space occupying lesion of unknown cause Guillain–Barré syndrome Transverse myelitis Distal sensory polyneuropathy Mononeuritis multiplex Vacuolar myelopathy Neurosyphilis
List some dermatological manifestations of HIV
Kaposi’s sarcoma
Severe or recalcitrant seborrhoeic dermatitis
Severe or recalcitrant psoriasis
Multi-dermatomal or recurrent herpes
zoster
HPV- huge warts with increasing tendency for dysplasia
Which cancers can be associated with HIV
Non-Hodgkin’s lymphoma
Kaposi sarcoma
Anal cancer or anal intraepithelial dysplasia
Lung cancer
Seminoma
Head and neck cancer
Hodgkin’s lymphom
Multi-centric Castleman’s disease (HHV8-mediated)
Cervical cancer
Vulval intraepithelial neoplasia
Cervical intraepithelial neoplasia grade 2 or above
List some manifestations of HIV seen in the eyes
Cytomegalovirus retinitis - leads to reduced acuity, floaters, abdo pain, diarrhoea and PR bleeding
Infective retinal diseases including herpesviruses and
toxoplasma
Any unexplained retinopathy
List some ENT manifestations of HIV
Lymphadenopathy of unknown cause
Chronic parotitis
Lymphoepithelial parotid cysts
What follow up is required for someone who has taken HIV PEP
Patients taking HIV PEP should have a 4th generation HIV
test (along with syphilis, HBV and HCV serology) and have
appropriate biochemistry tests, renal and liver function tests
done.
They should be advised to have:
• A single follow-up HIV test 8-12 weeks after exposure, using a 4th generation test
• To practise safer sex (condom use)
What are the Fraser Guidelines used for
To give contraceptive advice and treatment to a young person under the age of 16 without their parent’s knowledge
Only if they have the maturity and intelligence to give fully informed consent, cannot be persuaded to tell a parent, likely to have sex anyway, if it is in their best interest
How old do you have to be to consent to sexual activity in the UK
16
Some under 16s will have consensual sex (both must be competent and under 16) but must check for safeguarding
A child who has not yet reached the age of 13 is
incapable of consenting to any form of sexual activity
What is the definition of sexual assault
If a person (“A”) performs any sexual activity—
•without another person (“B”) consenting, and
•without any reasonable belief that B consents
Which sexual acts are considered sexual assault in Scotland (if done without consent)
Penetration - vagina, anus or mouth
Intentionally or recklessly touching sexually
Engaging in any other form of sexual activity in which the perpetrator intentionally or recklessly,
has physical contact (whether bodily contact or contact by means of an implement and
whether or not through clothing)
Intentionally or recklessly ejaculates semen onto someone
Intentionally or recklessly emits urine or saliva onto someone sexually.
What is the window for collecting forensic evidence in cases of sexual assault
7 days (168 hours) to capture DNA and bodily fluids
In order to avoid losing evidence in cases of sexual assault what should you do
Avoid:
• Bathing, showering, washing
• Douching
• Washing clothes worn at the time of the assault
• Urinating until after a forensic examination if choosing to have forensic capture
Preserve:
• Underwear and clothes worn at the time of the incident
• Sanitary pads/tampons worn at the time
• Condoms
• Retain tissue used to wipe after urinating
